Provider Demographics
NPI:1295040467
Name:BUSTOS, RACHEL L (SLP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:L
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10316 MAXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-6327
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:6601 MONTANA AVE
Practice Address - Street 2:SUITE G & H
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2155
Practice Address - Country:US
Practice Address - Phone:915-838-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX456606Medicare UPIN
TX676535Medicare UPIN